Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bella Terra Lagrange during CMS and state inspections, most recent first.
The facility failed to offer the COVID-19 vaccine to staff and did not document their vaccination status. The LPN/Infection Preventionist admitted there was no documentation showing the vaccine was offered. Staff were informed they could get vaccinated at clinics or pharmacies, but the facility did not actively offer it. The facility's policy required compliance with CMS, CDC, and IDPH guidance, but there was no documentation of staff education or vaccination status.
The facility failed to conduct and document required care plan meetings, and did not invite residents to participate in their care planning. Four residents, including those who are cognitively intact, reported not being aware of or invited to care plan meetings. The facility lacked documentation for these meetings, contrary to its policy and federal regulations.
A facility failed to label an IV antibiotic bag for a resident receiving Ceftriaxone for a liver abscess. The IV bag lacked necessary information such as date, time, and flow rate. The morning nurse confirmed the oversight, and the ADON stated the labeling requirements. The facility did not have a policy for IV bag labeling.
The facility failed to ensure proper labeling and secure storage of medications, affecting multiple residents. Medication blisters were improperly taped, and an insulin pen lacked labeling. Residents had medications at their bedside without proper orders or secure storage, including creams, eye drops, and Tums. Facility policies on medication storage and labeling were not followed, as confirmed by the ADON.
The facility failed to implement proper infection control measures, affecting multiple residents. A nurse did not perform hand hygiene between assisting residents during meals. A CNA did not clean hands after providing incontinence care, and another CNA failed to wear a gown and change gloves while caring for a resident under Enhanced Barrier Precautions. Soiled linen was also left on the floor in a resident's room. These actions violated the facility's infection control policies.
A resident's colonoscopy and EGD were rescheduled because the facility failed to hold a blood thinner as per physician's orders. Despite instructions to withhold Eliquis two days before the procedure, it was administered, leading to the inability to perform the procedure due to lack of IV access. The resident had a history of colon cancer and other significant health issues.
A nurse was observed standing over two cognitively impaired residents while feeding them, contrary to the facility's practice of maintaining dignity by being at the same eye level. One resident required partial assistance, while the other was totally dependent on staff for eating. The facility lacked a specific Residents' Rights policy but referred to a state-provided book mandating dignity and respect.
The facility failed to provide adequate ADL assistance to residents, resulting in unaddressed hygiene needs. A resident reported not being washed since admission, leading to discomfort and an unwanted beard. A CNA was unaware of their assignment to this resident. Additionally, two residents were observed with long, unclean nails, despite needing substantial assistance with personal hygiene. The ADON confirmed that staff are expected to provide such care according to the facility's policy.
A resident with multiple diagnoses, including a traumatic subdural hemorrhage and type 2 diabetes, exhibited signs of infection and abnormal vital signs. Despite orders from the NP to send the resident to the ER via 911, the facility used a regular ambulance, delaying urgent care. The decision was made after consultation between the RN and Nursing Supervisor, despite the resident's critical condition.
A resident experienced sexual abuse by a kitchen aide who exchanged inappropriate messages and photos with her, and made unwanted physical contact. Despite the resident's discomfort and attempts to maintain a friendship, the aide continued his advances. The aide admitted to exchanging phone numbers and sending photos but denied physical contact, claiming ignorance of the facility's abuse policies.
The facility failed to conduct a timely background check for a Kitchen Aide hired nearly three years prior, only completing it after an allegation arose. The facility's abuse prevention policy requires background checks and fingerprinting within 10 days of hiring, which was not followed, potentially compromising resident safety.
The facility failed to maintain comfortable air temperatures in resident rooms, affecting several residents who reported discomfort due to heat. Despite attempts to address the issue, room temperatures remained above the facility's comfort level policy, with high humidity levels exacerbating the situation. Maintenance staff did not effectively monitor room temperatures, and a malfunctioning air conditioner pump contributed to the problem.
The facility failed to ensure that call lights were within reach for two residents, as observed on 4/23/24. Both residents were unable to access their call lights, contrary to their care plans and the facility's policy. Staff interviews confirmed that call lights should always be accessible.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to its staff and did not maintain proper documentation of the vaccination status of its staff members. During an interview, the LPN/Infection Preventionist (V3) admitted that there was no documentation available to show that the vaccine was offered to staff. The facility's policy had changed, and the COVID-19 vaccines were no longer provided for free. Staff were informed that they could obtain the vaccine from clinics or pharmacies that accepted their insurance, but the facility did not actively offer the vaccine to them. Additionally, there was no documentation available to confirm that staff were educated about the benefits and potential side effects of the COVID-19 vaccine, nor was there any record of staff accepting and receiving the vaccine. The facility's policy, dated 7/16/24, stated that it would comply with CMS, CDC, and IDPH guidance on COVID-19 vaccination. Although CMS had rescinded the mandatory COVID-19 vaccine requirement for staff and residents, the facility was expected to continue promoting and providing the vaccine whenever available and with individual consent. However, the facility's infection control binders lacked any documentation of staff education or vaccination status, indicating a failure to adhere to its own policy and regulatory expectations.
Failure to Conduct and Document Care Plan Meetings
Penalty
Summary
The facility failed to conduct required care plan meetings and invite residents to participate in their care planning process. This deficiency was identified for four residents who were reviewed for care planning. Resident R32, who is cognitively intact, reported not knowing what a care plan meeting was and had never been invited to one. The facility was unable to provide any documentation of care plan meetings for R32 for the past year. Similarly, resident R69, also cognitively intact, stated he had never been invited to a care plan meeting despite being in the facility for over two years. The only care plan documentation available for R69 was dated several months prior, with limited attendees noted. Resident R79, who is cognitively intact, also reported not being invited to a care plan meeting, with documentation showing only family members and facility staff as attendees. Resident R20, with moderate cognitive impairment, had no documentation of care plan meetings in the past year. The Social Services Director acknowledged the lack of documentation and stated that residents should be invited to their care plan meetings to ensure their needs are met. The facility's policy requires care plans to be developed in conjunction with federal regulations, but this was not adhered to in these cases.
Failure to Label IV Antibiotic Bag
Penalty
Summary
The facility failed to ensure proper labeling of an IV antibiotic therapy bag for a resident, leading to a deficiency. During an initial tour, it was observed that a resident, who was lying in bed, had an empty IV bag of Ceftriaxone without any label indicating the date and time. The resident was receiving this antibiotic for an abscess in her liver. The morning nurse confirmed that the IV antibiotic was administered during the night shift but acknowledged that the bag should have been labeled with the date, time, flow rate, and room number. The Assistant Director of Nursing also stated that nurses are required to include the patient's name, medication details, start time, rate, and initial the bag. The facility was unable to provide an IV therapy policy that included the labeling of IV bags.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of medications, affecting eight residents. During a review of the medication carts, it was observed that medication blisters for hydrocodone-acetaminophen, pregabalin, and lorazepam were taped closed instead of being wasted, as per facility policy. The LPNs involved were unsure of the correct procedures for handling these medications. Additionally, an insulin aspart flex pen was found without a label indicating the resident's name or the dates it was opened and should be used by, which is against the facility's policy. Several residents were found to have medications at their bedside without proper physician orders or secure storage. One resident had Nystatin cream and lubricant eye drops in her bedside drawer, with no physician order for the eye drops. Another resident had a bottle of Tums in her drawer, which was not ordered by a physician. Similarly, a resident had a cup of Tums on her bedside table, which she stated was left by the nurse for her to take at will, despite the physician's order specifying a different medication. The facility's policies on medication storage, labeling, and disposal were not adhered to, as evidenced by the presence of medications in residents' bathrooms and on bedside tables. This included hydrocortisone cream and zinc oxide ointment found in a resident's bathroom, and an Albuterol inhaler and fluticasone nasal spray on another resident's overbed table. The Assistant Director of Nursing confirmed that medications should be locked and secured, and not left in residents' personal spaces for safety and hygiene reasons.
Infection Control Deficiencies in Resident Care and Linen Handling
Penalty
Summary
The facility failed to implement proper infection control measures during resident care and handling of soiled linen, affecting six out of seven residents reviewed for infection control. During a lunch service, a nurse was observed wiping food off one resident's mouth and then feeding another resident without cleaning her hands in between, continuing this practice throughout the meal. The Assistant Director of Nursing later confirmed that hand hygiene should have been performed between assisting each resident. In another instance, a CNA provided incontinence care to a resident without performing hand hygiene after wiping the resident's buttocks, subsequently touching bed linens and bedrails with contaminated gloves. The CNA acknowledged the lapse in hand hygiene, and the Wound Nurse present also noted the failure to clean hands. Additionally, another CNA failed to wear a gown while providing care to a resident under Enhanced Barrier Precautions, used the same washcloth for different areas without folding it, and did not change gloves or perform hand hygiene before applying barrier cream and handling objects in the room. The facility's infection control policies, including Enhanced Barrier Precautions and Hand Hygiene, were not adhered to, as evidenced by staff not wearing gowns during high-contact care activities and leaving soiled linen on the floor in a resident's room. The Assistant Director of Nursing confirmed that soiled linen should not be left on the floor and should be bagged and sent to the laundry. These observations indicate a failure to follow established protocols to prevent the spread of infections within the facility.
Failure to Follow Physician's Orders for Procedure
Penalty
Summary
The facility failed to follow physician's orders for a resident scheduled for a colonoscopy and an EGD. The gastroenterology office had sent a procedure reminder form indicating that the resident's blood thinner, Eliquis, should be held two days prior to the procedure. However, the resident's Medication Administration Record showed that the blood thinner was administered on the day it was supposed to be held, leading to the procedure being rescheduled. The resident, who had a history of colon cancer and multiple other diagnoses including pulmonary embolism and heart failure, was unable to complete the colonoscopy due to the administration of the blood thinner and the inability to establish intravenous access. The facility's administrator acknowledged that the nurse did not follow the doctor's orders, which resulted in the failure to perform the scheduled procedure.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure residents were treated with dignity while providing care, as observed during a survey. A nurse was seen standing over two residents while feeding them their lunch, which is against the facility's practice of maintaining dignity by being at the same eye level as the residents. This practice is important for the residents' comfort and respect. Both residents involved had severely impaired cognition, with one requiring partial/moderate assistance for eating and the other being totally dependent on staff for eating. The facility lacked a specific Residents' Rights policy but referred to a state-provided Residents Rights book, which mandates treating residents with dignity and respect.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for residents who required help to maintain their cleanliness and comfort. One resident, who had been in the facility since March 21, 2025, reported not having been washed since admission, resulting in discomfort due to sweat and an unwanted full beard. The resident expressed that staff did not introduce themselves and felt like a burden when requesting assistance. A Certified Nursing Assistant (CNA) admitted to not knowing the resident was on their assignment and stated that care would only be provided if time allowed after assisting other residents. Additionally, two other residents were observed with long, jagged nails with a brown substance underneath, indicating a lack of personal hygiene care. One resident's electronic health record indicated a need for substantial assistance with personal hygiene, while the other resident was noted to have severely impaired cognition and was dependent on staff for hygiene care. The Assistant Director of Nursing acknowledged that staff are expected to provide ADL care, including nail trimming, as per the facility's General Care policy, which aims to meet the residents' needs.
Failure to Use 911 for Resident with Critical Condition
Penalty
Summary
The facility failed to send a resident to the hospital emergency department via 911 after a significant change in condition. The resident, who was admitted with multiple diagnoses including traumatic subdural hemorrhage, lumbar vertebrae fracture, type 2 diabetes, and cognitive communication deficit, exhibited abnormal vital signs and laboratory results indicating a potential infection. On December 30, 2024, the resident's blood work showed elevated white blood cell count, and by January 1, 2025, blood cultures revealed staphylococcus aureus, with the resident displaying low blood pressure, high heart rate, and fever. Despite these concerning signs, the resident was not transported to the hospital via 911 as recommended by the Nurse Practitioner (V6), who was informed of the resident's condition and ordered immediate transfer for further evaluation and treatment. Instead, the resident waited for a regular ambulance, delaying the transfer. The decision to use a regular ambulance was made after consultation between the Registered Nurse (V7) and the Nursing Supervisor, despite the resident's critical condition. The Primary Care Physician (V3) and the Nurse Practitioner both indicated that the resident's condition warranted an emergency response due to the risk of sepsis and the need for immediate medical intervention. The failure to use 911 for transport was a significant oversight, as the resident's vital signs and laboratory results clearly indicated a need for urgent care, which was not promptly addressed by the facility staff.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by the interactions between a resident and a kitchen aide. The resident, a cognitively intact Spanish, American Indian woman with paraplegia and other medical conditions, reported that the kitchen aide kissed her and touched her chest. The inappropriate relationship began when they exchanged phone numbers and communicated through the WhatsApp application, where the aide sent inappropriate messages and photos to the resident. The resident described feeling uncomfortable as the kitchen aide's messages became increasingly inappropriate, asking about her catheter and making sexual comments. Despite the resident's attempts to maintain a friendship, the aide continued to send suggestive messages and photos, and visited her room on two occasions, during which he made unwanted physical contact. The resident did not report the incidents until she feared being discharged from the facility. The kitchen aide admitted to exchanging phone numbers and sending photos but denied any physical contact. He claimed he was unaware of the facility's policies regarding abuse and relationships with residents, although he acknowledged that personal relationships with residents were inappropriate. The facility's abuse and neglect policy clearly states that any sexual behavior or relationship initiated by a staff member with a resident is considered sexual abuse unless there was a pre-existing relationship prior to admission.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to adhere to its abuse prevention policy by not completing a timely background check for a new hire, identified as V3, a Kitchen Aide. V3 was hired on February 20, 2022, but the Illinois State Police background check was not conducted until December 9, 2024, nearly three years later. Additionally, the Illinois Department of Public Health (IDPH) Health Care Worker Registry initially showed no record of V3, indicating that the necessary checks were not performed at the time of hire. This oversight was discovered when an allegation involving V3 arose, prompting the facility to review his file and realize the absence of the original background check and fingerprinting. The facility's abuse policy, dated July 12, 2024, mandates that background checks and fingerprinting be conducted within 10 days of hiring for non-licensed staff, in compliance with federal guidelines for abuse prevention. The policy outlines seven components of prevention and investigation, including screening potential employees for any history of abuse, neglect, or exploitation. However, the facility did not follow these procedures for V3, as evidenced by the delayed background check and fingerprinting, which were only completed after the allegation surfaced. This failure to comply with established protocols potentially compromised the safety and well-being of the 99 residents residing in the facility.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable air temperatures in resident rooms, affecting 9 out of 9 residents reviewed for a homelike environment. Residents and their families reported that the rooms were too hot and uncomfortable, with air conditioning units providing insufficient cooling. The facility's maintenance staff attempted to address the issue by replacing and flushing air conditioner unit water lines, but the problem persisted, particularly during a heat wave when outdoor temperatures reached as high as 97 degrees Fahrenheit. Observations and measurements taken by maintenance staff and a journeyman from a contract company revealed that room temperatures ranged from 76.6 to 79 degrees Fahrenheit, with humidity levels between 55% and 62%. These conditions were above the facility's policy comfort level of 68-75 degrees Fahrenheit. The facility's policy also required ambient temperatures to remain between 71 and 81 degrees Fahrenheit, but the high humidity and warm temperatures in resident rooms and common areas indicated a failure to adhere to these guidelines. The facility's maintenance staff did not begin taking resident room temperatures until the outdoor temperatures rose above 80 degrees, and only surface temperatures were initially measured using a laser thermometer. The facility's policy on extreme high temperatures required random temperature checks of resident rooms and common areas, but these checks were not conducted effectively. The main air conditioner chilled water pump on the second floor was not working and was only repaired after the issue was identified, contributing to the uncomfortable conditions experienced by residents.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were within their reach, affecting two of the four residents reviewed. On 4/23/24, Resident 3 was observed sitting in her wheelchair with her call light wrapped around the upper left side rail, making it unreachable. Similarly, Resident 4 was found sitting in her wheelchair with her call light placed behind her on the nightstand, also out of reach. Both residents confirmed their inability to reach their call lights when needed. Interviews with staff, including a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA), revealed that it is standard practice to keep call lights within residents' reach. The facility's administrator also confirmed that call lights should always be accessible to residents. The care plans for both residents indicated that their call lights should be kept within reach, and the facility's Call Light Policy supports this requirement. Despite these guidelines, the facility did not comply, leading to the observed deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near La Grange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Manor - Lagrange | 1.3 mi | ★★★★★ | 4 | 0 |
| Plymouth Place | 1.6 mi | ★★★★★ | 3 | 0 |
| Grove Of Lagrange Park, The | 1.8 mi | ★★★★★ | 12 | 0 |
| Aperion Care Westchester | 2.4 mi | ★★★★★ | 4 | 0 |
| Briar Place Nursing | 2.5 mi | ★★★★★ | 25 | 0 |
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